VESSELS,

NERVES &
CONDUCTING
SYSTEM OF THE
HEART
DR. NWOSU C.I.A., MA, MSc, MBBS,
MD.

LEARNING OBJECTIVES

Origin of coronary arteries ; the anastomosis of their branches is potential

are functional end arteries,

The knowledge of the course , pattern and replacement (CABG) is essential because
coronary artery disease is the overall leading cause of death for men and women in the
United States,
Heart innervation is by autonomic nerves & visceral afferents which ride with the
sympathetic,

Cardiac conducting tissues consist of modified and specialized cardiac

muscle cells which lie immediately beneath the endocardium and carry
impulses to all parts of myocardium signaling for it to contract,
EKG : When one part of cardiac muscle depolarizes and becomes
electronegative relative to other parts, this generates electrical current,
Thus electrical current spreads from the electronegative part into adjacent
tissues (electropositive) all the way to the surface ; recordable on
electrocardiograph,
Disruption of the conducting tissue of the heart results in disruption of RATE
& RHYTHM of the heart,
Visceral pain is usually referred to the soma (as if it originated from soma)
because the brain is not smart enough to distinguish between the two : almost
always votes for soma because soma stimulates it more often than viscera

VESSELS OF THE
HEART

ARE CORONARY ARTERIES, CARDIAC VEINS, CARDIAC LYMPHATICS,

These vessels are embedded in the epicardial fat,

Coronary arteries are considered as functional end
arteries = potential anastomoses (no anastomoses, no
overlap) ; where they do exist, they cannot provide
collateral circulation fast enough in situations of a block,
While peripheral arteries fill during systole, coronary
arteries fill during diastole due to aortic recoil,
Cardiac veins are valveless,
Most capillary beds of the heart drain into the RT atrium,
The blood vessels receive both parts of the autonomic
nervous system

CORONARY
ARTERIES

CORONARY ARTERIES

There are usually 2 coronary

arteries,
They are branches of ascending
aorta and they take origin from
aortic sinuses above their
respective valve cusps of aortic
valve,,
Coronary arteries take nutrients
directly to epicardium and
myocardium, and indirectly to the
endocardium and
subendocardium via diffusion,
They are considered as functional
end arteries : anastomoses exist
but they are not large enough to
provide edequate blood supply in Blood flow through the coronary arteries
cases of blockage,
is greatest during DIASTOLE when the
Course : along atrioventricular
MYOCARDIUM IS RELAXED and the
grooves.
AORTIC VALVE IS CLOSED.

ORIGIN OF CORONARY
ARTERIES

RT coronary
ostium

Coronary
sinuses

Ascending
aorta

LT coronary
ostium

RIGHT & LEFT CORONARY

ARTERIES
RIGHT CORONARY ARTERY

ORIGIN : Rt aortic sinus,

COURSE : between RT auricle and
conus & in AVG,
GEN. BRANCHES : VICAN ;
V for ventricular,
I for interventricular septum
(perforators)
C for conus,
A for atrial
N for nodal
CRUX : where AV nodal branch is
given off,
DISTRIBUTION :
RT atrium,
Rt & LT ventricles on the
diaphragmatic surface
posterior 1/3 of IVS (one of
perforating branches),
both nodal tissues
POTENTIAL ANASTOMOSES : with
circumflex, LADA, & perforators

LEFT CORONARY ARTERY

ORIGIN : LT aortic sinus,

COURSE : between LT auricle and conus
& in AVG,
GEN. BRANCHES : VICAN ;
V for ventricular,
I for interventricular septum
(perforators)
C for conus,
A for atrial
N for nodal
DISTRIBUTION :
LT atrium,
Lt ventricle (most)
RT ventricle (some)
anterior 2/3 of IVS including bundle of
His
nodal
POTENTIAL ANASTOMOSES : with RCA,
PIVA, & perforators

RIGHT CORONARY ARTERY

a. of conus anastomoses with LAD
(arterial circle of Vieussens)
a. of the SA node
60%
right anterior ventricular brr.

right marginal a.

right posterior ventricular brr.

anastomoses with left
circumflex a. (LCX) at
the crux
a. of the AV node

septal brr.
anastomoses
with LAD

posterior descending
(PDA) a.
anastomoses at the
apex with LAD

LEFT CORONARY ARTERY

left coronary a.
left coronary circumflex (LCX) a.

diagonal brr.
left anterior
descending
(LAD) a.
anastomoses
with a. of conus
& at
the apex with
PDA

septal brr.
anastomoses
with PDA

left marginal a.

left posterior
ventricular brr.
anastomoses
with RCA

LEFT
RIGHT

CORONARY
DOMINANCE
Defined by which
of the 2 coronary
arteries gives off
the posterior
interventricular
artery (PIVA) :
Right in 65 67
%,
Left in 15 25 %,
Co-dominance or
balanced heart &
absent dominance
in about 10%

Right dominance

?co
dominance

Left
dominance

? dominance

CORONARY CIRCULATION
TESTED
A 55-YO man presents at the ER
A 58-YO man undergoes

coronary angiography to with a complaint of crushing

chest pain. His labs reveal
evaluate his coronary
arteries. the cardiologist elevated cardiac enzymes
suggesting acute MI.
notes that he has a left
echocardiography confirms
dominant heart. Which
akinetic segment of the left
of the following arteries
ventricle and anterior part of
would the posterior
IVS. Which of the following
interventricular artery
arteries is the most likely
be a branch of in this
obstructed?
patient?
A. Anterior interventricular artery
A. Left anterior descending
B. Posterior interventricular
B. Left marginal
artery
C. Right marginal
C. Right coronary artery trunk
D. Right coronary
D. Right marginal artery
E. Circumflex
E. Left marginal artery

ANASTOMOS
ES

1.
2.
3.
4.

Vascular anastomosis is
communication
between vessels,
Anastomosis of
coronary arterial
branches is POTENTIAL,
Communication
between right and left
coronary aa.
a. of the conus with
LAD (arterial circle of
Vieussens)
interventricular septum
by septal perforators
LAD with PDA
cardiac apex between
LAD with PDA
at the crux between
LCX & PDA
ML

ARTERY OF SUDDEN DEATH

1st septal perforating branch of LAD

supplies muscular septum at
the point where right and left
bundle branches (from AV node)
divide
occlusion of this vessel (or the
LAD proximal to the branch)
block blood supply to this area
this interrupts the smooth
passage of cardiac impulses to
the apex of the heart
the consequent poor
organization (or lack of
distinct path) of AV node
impulses yields erratic
ventricular contractions
this is often related to or
interpreted as a heart rate
of approximately 40 beats
per minute

VARIATIONS OF
CORONARY
ARTERIES

Variations are most

common in the supply of
the diaphragmatic
surface of both ventricles
- PIVA,
This artery determines
dominance,
Right in 65 67 %,
Left in 15 25 %,
Co-dominance & absent
dominance in about 10%
Some people have only
one coronary artery,
while some have one too
many (4%),
In some the circumflex
artery arises from RCA

CARDIAC VEINS &

LYMPHATIC
DRAINAGE

VENOUS & LYMPHATIC DRAINAGE OF

THE HEART
VENOUS DRAINAGE

LYMPHATIC DRAINAGE

The collecting vein of the heart is

coronary sinus : formed by great
Small lymphatic vessels
cardiac vein & oblique vein of
of the heart are located
Marshall (of left atrium),
in the subendocardial
Veins that drain into coronary sinus,
connective tissue & in
- great cardiac vein (accompany LADA),
- middle cardiac vein (accompany PIVA),
- small cardiac vein (accompany Rt
marginal artery)
- left posterior ventricular vein
- oblique vein of Marshall (of left atrium),
Veins that do not drain into coronary
sinus:
- anterior cardiac veins,
- vanae cordis minimae

the myocardium,
These drain into the
cardiac lymphatic
plexus located in the
subepicardial fat,
Lymphatic vessels from
the plexus ultimately
drain into the tracheobronchial lymph nodes

ANTERIOR
VIEW

Why is it that systemic blood will never be 100% saturated with oxygen?

INNERVATIO
N OF THE
HEART

INNERVATION OF HEART
Heart innervation is by autonomic nerves,
The heart is supplied by cardiac plexus which
consists of post-ganglionic sympathetic fibers, preganglionic parasympathetic fibers and visceral
afferent (sensory fibers),
Sympathetic : all three cervical from T1 T4/5
thoracic ganglia; to coronary arteries and nodes :
SAN & AVN, (SAN),
Parasympathetic : 2 vagus nerves & 2 RLNs; to
arteries and atrial wall (APA),
The heart is special in that its coronary vessels
receive both sympathetic and parasympathetic
innervations: thus both components of the autonomic
nervous system have direct vascular influence,
Visceral afferent fibers : pain fibers run with the
sympathetic and enter the spinal cord in
corresponding segments,
Referred pain in the chest, shoulder, arm, or neck;

why?

Sympathetic
Input
heart rate

superior cervical
ganglion

contractile force

superior cervical
(sympathetic) cardiac n.
middle cervical
ganglion
middle cervical (sympathetic) cardiac n.
stellate (inferior cervical;
thoracic) ganglion

inferior cervical
(sympathetic) cardiac n.

T1-T-5

Adrenergic influences other than

sympathetic impulses (I.e. hormonal)
will also increase heart rate &
contractile force

PARASYMPATHETIC PATHWAY
Dorsal Motor nucleus of vagus nerve in
medulla to
Vagus nerves (pre-ganglionic)
Ganglia in atrial wall/inter-atrial septum, &
coronary arteries,
PARASYMPATHETIC STIMULATION:
Heart rate,
Impulse conduction,
Force of contraction,
Flow to coronary vessels.

Parasympathetic Input
heart rate
contractile force

brain stem

dorsal motor nucleus of vagal

superior, middle & inferior

cervical (vagal) cardiac brr.

non-cardiac brr. In
thorax & abdomen.

cardiac ganglia

SENSORY INNERVATION
sensory (visceral afferent) axons from the
heart travel alongside sympathetic
(efferent) axons going to the heart, with
cell body in DRG,
afferent signals from the heart reach the
spinal cord at similar levels to afferent
signals from other regions of the body :
most notable is the left shoulder and arm
A typical example is the baroreceptor reflex,

SINUS REFLEX

(baroreceptor reflex)

arterial blood pressure

stimulation of receptors in the carotid sinus
stimulation of parasympathetic system through
carotid sinus nerve to the nucleus of solitary tract
increased parasympathetic input to heart

arterial blood pressure

heart rate
contractile force

Baroreceptors are
mechanoreceptors. They are
spray type nerve endings
that respond to stretch in the
wall of vessels.

CARDIAC CONDUCTING
TISSUES

Cardiac conducting tissues

consist of modified and
specialized cardiac
muscle cells which lie
immediately beneath the
endocardium and carry
impulses to all parts of
myocardium signaling for
it to contract,

Consists of SAN, AVN, AVB,

AVBBs and purkinje fibers
VALUE OF CARDIAC
CONDUCTION TISSUE : produces
coordinated contraction of the
heart,

SAN; between the superior end of

crista terminalis & inferior end of
SVC, in the anterior wall of Rt
atrium. Initiates heartbeat
(pacemaker) because it has
intrinsic rhythmicity and
automaticity that generate a wave
of depolarization which spread in
the atria,

http://health.howstuffworks.com/adam-200080.htm

CARDIAC CONDUCTING
TISSUE

AVN : between the inferior end of

interatrial septum and septal leaflet
of tricuspid valve; receives impulses
from SAN and passes them to AVB.
AVN is the only tissue through which
impulses pass from atria to ventricles.
AVB : in the membranous part of
interventricular septum; carries
impulses to cardiac apex via Rt. & Lt.
bundle branches in the IVS,
BUNDLE BRANCHES : in the
muscular part of interventricular
septum: Rt. Bundle branch takes
impulses through the Moderator band
to anterior papillary muscle
Waves spread spirally from apex back
up to fibrous skeleton : causes
ventricular wringing and efficient
ejection of cardiac output,
PURKINJE FIBERS, which are
terminal conducting fibers which are
located in all parts of ventricular wall.,

SUMMARY
CORONARY ARTERIES, CARDIAC
VEINS/CORONARY SINUS,
AUTONOMIC INNERVATION FOR
REGULATION/CONTROL,
CARDIAC CONDUCTION TISSUE MADE
UP OF PURKINJE FIBERS WHICH ARE
MODIFIES MYOCYTES.

PRACTIC QUESTIONS

What is the artery of sudden death?

During a CABG, a cardiothoracic surgeon, in an effort to
clamp, ligate and remove a blocked segment of
posterior interventricular artery (PIVA), punctures the
vein that accompanies that artery (PIVA), what vein has
been injured?
If a coronary angiogram shows a thrombus in the
posterior interventricular artery (or circumflex artery),
the function of which parts of the heart would be
affected?
What is/are the artery/arteries that supply the cardiac
apex?
An aneurysm of the arch of aorta is likely to compress
which structures?

THANK
YOU

Baroreceptor
reflex
glossopharyngeal
ganglia

arterial blood
pressure

carotid
sinus
solitary nucleus
reticular formation
dorsal vagal nucleus
Cardiac
Ganglia
(on the heart)

THE BARORECEPTOR REFLEX IS

SENSORY, NOT AUTONOMIC

heart rate
contractile force

HEART BLOCK

disruption of the AV node, bundle or bundle branches : results

ventricles will beat slowly, independent of the atria
atrial contractions are still determined by SA node
1st degree
PR interval on ECG slowed (>0.2s)
no treatment required in most cases
2nd degree : Dropped beat
greater hindrance of impulses, irregular appearance of QRS wave on ECG
gradual accumulation of delays eventually amounts to a dropped beat (known as
Mobitz type I)
may cause dizziness, shortness of breath, especially during exercise
should the hindrance be greater, the succession of dropped beats appears as an
overly slow heart rate (Mobitz type II) : more serious, may require a pacemaker
3rd degree (complete)
no atrial impulses reach the ventricles, there may be no QRS wave on ECG
AV node maintains base-line rate of contraction (average = 40/minute)
AV node irresponsive to SA node changes
may be caused by heart disease, drug toxicity, drug interactions
can be cause of death if ventricular contractions are insufficient

AORTIC ANEURYSM

DEFINITION : An aneurysm is a weakened and dilated portion of an artery,

WHAT WEAKENS AN ARTERY? 95% due to atherosclerosis ; others (5%) are
due to trauma, syphilis, mycosis & Marfans syndrome. Majority occur in the 6 th & 7th
decades of life,
COMMON SITES: Aortic aneurysms are most common below the diaphragm (AAA)
- over 95% of AAA occur below the renal arteries,
- over 95% of all symptomatic AAA will be dead before 5 years,
COMPLICATIONS : rupture, embolization, thrombosis, infections, coagulopathy , A-VF

AORTIC DISSECTION
DEFINITION : a tear in the wall of aorta so that blood flows between
the layers of the wall, further forcing the walls apart,
COMPLICATIONS: rupture. Aortic dissection is a medical emergency,
which can quickly lead to death due to massive blood loss, even with
optimal treatment

CORONARY ARTERY
DISEASE

Atherosclerosis,a type of arteriosclerosis, is the commonest coronary artery

disease,
Others are Monckebergs medial calcific sclerosis & arteriolosclerosis,
Atherosclerosis is the # 1 killer in the U.S.A.,(> 700, 000 deaths per year) : affects
about 13 million Americans,
Operates by depositing lipids & fibrous tissue in tunica media = fibrofatty plaques
that may become calcified,
No tissue is spared, but the following are worst hit : heart, brain, kidneys and eyes,
Plaques are usually patchy but are prominent around ostia of large vessels such as
coronaries, renal popliteal & Wilis circle vessels,
PATHOPHYSIOLOGY:
STEP 1: subendothelial deposit of lipids (core),
STEP 2 : entry of monocytes become macrophages,
STEP 3 :entry of smooth muscle cells
STEP 4 : fibrous tissue formation (cap) & calcification,
STEP 5 : complications ulceration, rupture, aneurysm, embolization,

MYOCARDIAL INFARCTION (MI)

Myocardial ischeamia converts to myocardial infarction (necrosis),

Anterior chest pain now lasts longer that 30 minutes, and is more severe & progressive, and is not
related to activity early morning, may wake patient up; in diabetics MI usually painless,

Other symptoms are sweating, weakness, anxiety, light-headedness, fainting,

dyspnea, cough, nausea, vomiting, palpitations. Women may experience fever,
EKG : ST- segment elevation or depression, evolving Q wave, symmetrical inversion of T wave,
ELEVATION OF CARDIAC MARKERS : creatinine kinase MB (CK-MB), Troponin-T or Troponin-I,
IMAGING : segmental wall motion abnormality

MYOCARDIAL INFARCTION (MI)

contd.
RISKS & PRECIPITATING
FACTORS

Constitutional: age, sex,

genes (hyperlipidemia,
hypertension, hyperglycemia)
Acquired : diet, lifestyle
WESH (W for weight; E for
exercise; S for stress, H for
habits, including cigarette
smoking)
Precipitators : (a) stress,
(b) strenous exercise after a
heavy meal, (c) sudden
exposure to cold

COMPLICATIONS:

Cardiac rupture
syndromes;
- chamber wall,
- interventricular
septum,
- papillary muscle,
- hemorrhage,
Fibrinous
pericarditis,
Sudden death,

A complication of M.I.

Anterior wall hemorrhage

Anterior wall
rupture

Rupture of ventricular septum

Papillary muscle rupture

Fibrinous pericarditis

REMEDIES
CORONARY ARTERY BYPASS GRAFT (CABG),
PERCUTANEOUS TRANSLUMINAL
CORONARY ANGIOPLASTY :
- dilatation,
- insertion of stent,
- injection of enzyme, streptokinase to
dissolve clot.

Percutaneous
Transluminal
Coronary
Angioplasty
(PTCA)

Balloon angioplasty
before

after

CABG

CABG

CABG

The formatio reticularis of the medulla

oblongata, shown by a transverse section
passing through the middle of the olive.
(Testut.) 1. Anterior median fissure. 2.
Fourth ventricle. 3. Formatio reticularis, with
3, its internal part (reticularis alba), and 3,
its external part (reticularis grisea). 4. Raphe.
5. Pyramid. 6. Lemniscus. 7. Inferior olivary
nucleus with the two accessory olivary nuclei.
8. Hypoglossal nerve, with 8, its nucleus of
origin. 9. Vagus nerve, with 9, its nucleus of
termination. 10. Lateral dorsal acoustic
nucleus. 11. Nucleus ambiguus (nucleus of
origin of motor fibers of glossopharyngeal,
vagus, and cerebral portion of spinal
accessory). 12. Gracile nucleus. 13. Cuneate
nucleus. 14. Head of posterior column, with
14, the lower sensory root of trigeminal
nerve. 15. Fasciculus solitarius. 16. Anterior
external arcuate fibers, with 16, the nucleus
arcuatus. 17. Nucleus lateralis 18. Nucleus of
fasciculus teres. 19. Ligula.

The three-layered, four-chambered

double pump