Cardiovascular Anatomy,
Physiology and Pathophysiology
• Thanks to:
– SICP
– Andrea Davis RCIS, FSICP
– Wes Todd, Cardiac Self
Assessment
– Morton Kern, MD

Cardiovascular Anatomy,
Physiology and Pathophysiology
• Normal Cardiac and Vascular A & P
• Coronary Artery Anatomy
• Coronary Artery Disease
• Aortic and Mitral Valve Disease
• Septal Defects

Disclosure Information
Cardiovascular Anatomy, Physiology
and Pathophysiology
Jeff Davis RCIS, FSICP
The following relationships exist related to this presentation:
None
Off label use of products will not be discussed in this presentation.

The Cardio vas c ular S ys te m
 Heart –the pump
 Vasculature –the conduits
 Pulmonary circuit
 System circuit
ic

Cardiac Anatomy

The Vas c ulature
 A closed system of vessels that moves blood around the body
 Arterial vessels: aorta, arteries, arterioles (vascular resistance)
 Carry blood aw from the heart to the:
ay
 Capillary beds
 Venous vessels: venules, veins, venae cavae
 Carry blood tow the heart
ard

The Capillary Be ds

The He art
A 4-c hambe re d o rg an lo c ate d in the middle me dias tinum

Functional Purpose of the Heart
• Four Chamber pump that
provides blood supply to:
– Systemic circulation
left heart
– Pulmonary circulation
right heart
• Rig ht and le ft atria : re c e iving
c hambe rs
• Rig ht and le ft ve ntric le s :
pumping c hambe rs
• Suspended at the base by the
great vessels

Pericardium
• Fibroserous sac
surrounding the heart
• Folds in upon itself at the
level of the great vessels
to form the visceral and
periatal pericardial
surfaces
• Continuous with the
epicardium
– Forms epi/pericardial
surface
• Normally contains
approx. 30-50 cc of fluid

Heart Wall
• Epicardium
– Outer layer, inner
visceral layer of
pericardium
• Myocardium
– Middle muscle layer,
interlacing bundles of
fiber
• Endocardium
– Inside of the heart,
covers valves

Myocardium
• Interlacing fibers of
specialized muscle
– Some cells have the
ability generate intrinsic
electrical impulse
• Performs the work of the
heart
• Makes up the majority of
the mass

Calcium, Magnesium, ATP

Heart Wall
Figure 20.4

Cardiac Chambers

Right Atrium (RA)
• Receives blood from
the body or systemic
venous circulation
• Forms the right
cardiac border
• Receives blood from
vena cava (SVC &
IVC) and coronary
sinus

Right Ventricle (RV)
• Provides blood flow to
the pulmonary circuit
• Low pressure pump
– <35 mmHg
• Crescent-shaped
wraps around the LV
• Most anterior heart
structure

Left Atria (LA)
• Receives blood from
the lungs (oxygenated)
• Smooth walled except
appendage
• Most posterior cardiac
chamber
• Receive blood through
right and left
pulmonary veins

Left Ventricle (LV)
• Provides blood flow to
the systemic circuit
• High pressure pump
– >100 mmHg
• Egg shaped (ellipse)
• Forms the left cardiac
border

Structural Differences between the
Left and Right Ventricles
Figure 20.7a-c

Cardiac Tissues
• Annuli fibrosi
– Non-conducting
fibrous connective
tissue
– Referred to as the
skeleton
– Forms support for the
valves tissue (annulus)
– Separates the atria
and ventricles and
ventricles and great
vessels

Valves of the Heart
Figure 20.8a

Atrioventricular:
Mitral and Tricuspid
• Separate the atria and their
respective ventricles
• Tricuspid, Bicuspid
• Attached at the base to the
annulus and at the tips to the
papillary muscles via chordae
tendinea

Semilunar: Aortic and Pulmonic
• Separate the
ventricles and their
respective arteries
• Three cusp, attached
at the base to the
annulus
• Pressure sensitive
valve, opening and
closing activated by
change in pressure

Coronary Arteries
• Supplies blood supply to
the heart
• Two primary arteries from
the aorta
• Left
– Left Main
– Left Anterior Descending
– Circumflex
• Right
– Right
– Posterior Descending

Heart Casts - Muscle Removed

Left Coronary Artery
• Most of LV, LA, BB’s in IVS
• Left Main
• LAD (anterior, apical and septal LV)
– Diagonal branches
– Septal perforators
• Circumflex (posterior and lateral LV)
– Left atrial branch
– Obtuse Marginal branches
– Posterior descending artery (if left dominate)
• Intermediate Ramus

Left Main
LAD
Left atrial branch
Septal perforators
Diagonal
Circumflex
Obtuse Marginal

Right Coronary Artery
• RA, RV, Inferior LV, SA Node, AV Node
• Conus branch (RVOT)
• Sinus node branch (SA node, RA)
• RV Branches
• Acute Marginal branches (RV)
• AV nodal artery (AV node, IAS)
• Posterior descending artery (inferior IVS)
• Left ventricular branch-PLA’s (inferior LV)

Conus branch
Sinus node branch
RV branch
Left ventricular branch
Acute Marginal Posterior descending artery

RAO
Septal Diagonal
Circumflex LAD

Right Coronary Angiogram-RAO

RCA RAO

LAD

• TWO PARALLEL
PROCESSES PLAY
IMPORTANT ROLE IN
ATHEROSCLEROSIS:
• First the fats:
LIPID ACCUMULATION
& OXIDATION
• Then the vessel
deforms:
– ENDOTHELIAL
DYSFUNCTION causing
– Spastic vessels

Evolution of fibrous plaque
8. Muscle cells die
& harden plaque
-Calcium develops
Foam Cells
1 LDL Monocyte
Cell adhesion
factors macrophage
endothelium
1. LDL enters 3. Monocytes adhere & 4. cross 5. Macrophages Eat 6. muscle cells multiply &
2. & Oxidizes intima become macrophages Fat become Foam 7. enter intima
cells

Fuster V, et al. N Eng J Med 1992;326:311-318. 2. Photos courtesy of Boehringer Ingleheim International GmbH, by Lennart
Nilsson

Coronary Artery Disease

Thrombus Formation and ACS
Plaque Disruption/Fissure/Erosion
Thrombus Formation
Old
Terminology: UA NQMI STE-MI
New Non-ST-Segment Elevation Acute ST-Segment
Terminology: Coronary Syndrome (NSTEMI-ACS) Elevation
Acute
Coronary
Syndrome
(STEMI-ACS)

Myocardial Infarction
• Left Heart MI
– Dec. SV, CO/CI, AO,
systemic perfusion
– Inc. LVEDP, LA/PCWP, PA,
pulmonary congestion
– Left side heart failure
• Right Heart MI
– Dec. PA, LVEDP, AO,
systemic perfusion
– Inc. RVEDP, RA/CVP,
systemic venous
congestion
– Right side heart failure

Aortic Stenosis
• Normal aortic valve • Severe aortic stenosis
area is 2.5 to 4.0 cm2 less than 0.7 cm2

Mitral Stenosis
LV/PCW
LV Down stroke
Bisects V-wave of PCW
Normal mitral valve area -- 3.0 to 6.0 cm2
Severe mitral stenosis less than 1.0 cm2

Hemodynamic effects
of heart rate
80 bpm:
• tachycardia exacerbates LA
emptying dysfunction
• loud S1
• loud MDM, PSM
110 bpm:
• loud murmur was thought to be
systolic by house staff
• murmur ends with loud S1
• mid-diastolic murmur
66 bpm:
• each component can be heard
• loud S1, S2/OS, MDM, PSM

Mitral Regurgitation
• Leakage of blood across a closed mitral
valve during ventricular systole

Hemodynamics of
Acute and Chronic
Normal:
• S1, S2, no murmurs
Mitral valve prolapse:
• midsystolic click, possible late
systolic murmur of MR
Acute MR:
• here, from chordal rupture
• loud S1, initiates explosive
systolic murmur
• S3 with mid-diastolic murmur
Compensation:
• increased compliance of LA, LV
• blowing holosystolic murmur
• mid-diastolic rumble

Ostium Secundum ASD

Atrial Septal Defect
• Shunt left to right
• RA saturation increase
– SvO2 step up above normal high 60’s to mid
70’s%
• RA pressure increase
– Increase above normal 2-6 mmHg
• RV & PA blood contains venous and arterial
blood-
– Increase in O2 & pressures
• PBF > SBF
– May lead to heart failure
• Shunt can switch and go right to left
– Eisenmenger syndrome
– Based on PVR & SVR

Review
• Normal Cardiac and Coronary A & P
• Coronary Artery Disease
• Aortic and Mitral Valve Disease
• Septal Defects

Next up-
Michael Guiry, RPA-C
Thank You