Anatomy

The heart is a hollow muscular organ which functions as a pump distributing the blood through the blood vessels to all parts of the human body. This is of course very important because the function of the circulation is to maintain optimal conditions for survival and functioning of the cells, which is mainly achieved by distributing substrates and oxygen to the tissue, as well as collecting waste products and carbon dioxide. Secondary functions of the cardiovascular system are: control of blood flow to the skin and extremities to enhance retard heat loss, distribution of hormones and delivery of antibodies, platelets, and leukocytes to aid body defense mechanism.

The heart is located just behind the middle part of the front thorax wall and in most people approximately 2/3 of it are located on the left side and 1/3 on the right side. Its shape can be compared with that of a reversed cone. On the heart, just as on the cone, we can distinguish the wider end, or the base, and the blunt point called the apex. Heart base is directed upward, backward, and to the right, while the apex is directed downward, forward, and to the left. Imaginary line passing through the center of the base and the apex is called the axis of the heart (not to be confused with the electrical axis of the heart), and it too is following the same direction (up, right and back - down, left and front). It is important to be familiar with the axis of the heart, since it determines the placement of the electrodes during the electrocardiography.

Surface markings
* Apex is at mid-clavicular line of 5th intercostal space. * Inferior border passes horizontally to right sternal edge at level of sixth rib. * Right border passes along right sternal edge between 3rd and 6th ribs. * Left border is oblique and runs from left sternal edge at 2nd rib to apex. * Superior border crosses sternum between 3rd rib on right and 2nd rib on left.

Physiology
Although humans have one heart, from a functional point of view we can think of two pumps in series connected by the pulmonary and systemic circulations, the left heart and the right heart. Each of these hearts is further divided into two chambers. So the heart has four chambers in total, left and right atrium, as well as left and right ventricle. Atria, the pre-chambers, mainly function as the helpers of the ventricles by filling them with more blood before their contraction. The function of the right side of the heart is to collect de-oxygenated blood, in the right atrium, from the body and pump it, via the right ventricle, into the lungs (pulmonary circulation) so that carbon dioxide can be dropped off and oxygen picked up (gas exchange). The left side collects oxygenated blood from the lungs into the left atrium. From the left atrium the blood moves to the left ventricle which pumps it out to the body. On both sides, the lower ventricles are thicker and stronger than the upper atria, since they produce the greatest part of the force needed to pump the blood. The muscle wall surrounding the left ventricle is thicker than the wall surrounding the right ventricle due to the higher force needed to pump the blood through the systemic circulation.

Types of cardiac muscle and their function

Cardiac cells The heart is composed of three major types of cardiac muscle: atrial muscle, ventricular muscle, and specialized excitatory and conductive muscle fibers. The atrial and ventricular types of muscle contract in the same way as skeletal muscle, and they are the workers responsible for contraction. On the other hand, the specialized excitatory and conductive fibers contract only feebly, but instead they exhibit automatic rhythmical electrical discharge in the form of action potentials and conduction of the action potentials through the heart. These fibers form an excitatory system that controls the rhythmical beating of the heart, telling the workers to contract. Basically all cardiac muscle fibers can produce electrical discharge, but the rate of it varies. Atrial and ventricular muscle fibers have a much slower rate of discharge than the specialized excitatory and conductive fibers and that is why they normally do not have a chance to pace the heart. The fastest discharge comes from a part of the specialized excitatory and conductive fibers called the sinus (SA) node, which therefore is the normal pacemaker of the heart. The isolated SA node has a firing rate of 90-120 beats/min. The actual heart rate of an adult is approximately 70 beats/min because some intrinsic factors like vagal nerve activity slow it down a bit.

Heart conduction pathway Normal conduction pathway in the heart starts in the SA node, located in the wall of the right atrium, because this is where the normal rhythmical impulse is generated and is then conducted to the atrioventricular (AV) node by the internodal pathways. From here the AV bundle conducts the impulse from the atria into the ventricles where the left and right bundle branches of so called Purkinje fibers conduct the cardiac impulse to all parts of the ventricles. Impulses are also conducted by the atrial and ventricular muscle fibers, the only difference is in the speed of conduction which is much slower in this case than in the case of specialized conductive muscle fibers. Another important thing to mention when we talk about impulse conduction is its slowing in the AV node. When the impulse is generated in the SA node, it spreads through both right and left atrium via the atrial muscle and some conductive muscle fibers, and atria simultaneously contract. But they do this just a fraction of a second before ventricles, because the impulse hasnt yet spread through them since the AV node delayed it for about 0.13 seconds. This delay is important because it allows time for the atria to empty their blood into the ventricles before ventricular contraction begins, thus allowing for more blood to be pumped out. Table 1. Cardiac Conductive Properties Tissue SA node Fiber Diameter (m) ... Resting Membrane Potential (mV) 40-50 Conduction Velocity (m/s) 0.05

Atrial muscle Internodal tracts AV node Purkinje fibers Ventricular muscle

8-10 F15-20 Variable 70-80 10-16

R70-80 80-90 50 70 80

0.3-0.5 1.0 0.02-0.05 2.0-4.0 <1.0